Search

Purpose: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. Methods: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative’s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. Results: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. Conclusion: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]

The aim of this study was to assess the impact of tocilizumab on bone oedema in rheumatoid arthritis (RA) as shown by magnetic resonance imaging (MRI). In this longitudinal study, patients with rheumatoid arthritis according to the American College of Rheumatology (ACR) 2009 criteria with inadequate response or intolerance to disease-modifying anti-rheumatic drugs (DMARDs), treated with tocilizumab, were included. Sociodemographic characteristics and clinical and laboratory data for the disease were collected at baseline (M0) and 06 months (M6) of treatment. Disease activity was assessed using disease activity score in 28 joints (DAS28), simplified disease activity index (SDAI) and clinical disease activity index (CDAI). MRI of the dominant hand was performed at baseline and M6 of treatment. The primary outcome measure was the assessment of bone oedema by rheumatoid arthritis MRI scoring system (RAMRIS) bone oedema. Secondary outcomes included RAMRIS synovitis, DAS28, C-reactive protein (CRP) and SDAI at baseline and M6. Twenty-two patients with RA were included, 19 females (86.4 %), with a mean of age 42 ± 13.7. The mean disease duration was 8 ± 5.2 years. The mean DAS28 was 5.78 ± 0.87. The median CRP was 16 mg/l (6.7 to 36.3). The average SDAI was 90 ± 34. Three patients were excluded from the study for serious side effects. At baseline, bone oedema was present in 41 % of patients (N = 9), with a median bone oedema RAMRIS 0 (0 to 7.2). At M6, bone oedema decreased or disappeared in 32 % (N = 7) with a significant improvement in the RAMRIS bone oedema score (p = 0.04). Moreover, there is a significant improvement in RAMRIS synovitis (p < 0.0001) as well as in activity parameters: DAS28 (p < 0.0001), CRP (p < 0.0001) and SDAI (p < 0.0001). This study suggests that tocilizumab is associated with a significant improvement on MRI-determined bone oedema in the short term. This improvement in bone oedema is correlated with improved parameters of disease activity, in which early structural effect could be discussed. Further studies are needed to confirm these results.

The objective of this study was to evaluate sexual function in women with rheumatoid arthritis (RA) using an auto-questionnaire Female Sexual Function Index (FSFI) and study its correlation with disease activity. Sixty patients with RA and 40 healthy controls were included in this exploratory study. Sociodemographic, clinical, and laboratory characteristics were assessed. The disease activity was assessed by auto-questionnaires Routine Assessment of Patient Index Data 3 (RAPID3) and Rheumatoid Arthritis Disease Activity Index 5 (RADAI5) judged by 28 DAS ESR. Sexual function was assessed by an auto-questionnaire specific for female sexuality: FSFI during the last 4 weeks. The definition of sexual dysfunction was considered by FSFI score less than or equal to 26.5. The mean age of RA patients and controls was 45.95 ± 9.3 and 45.01 ± 9.2, respectively. According to FSFI, the percentage of FSD in women with RA was significantly higher than that in the control group. All dimensions of sexuality were affected (desire, arousal, lubrication, orgasm, and satisfaction) except pain. The multivariate linear regression analysis indicated that the swollen joints and the RADAI5 were the independent variables of disease activity associated with sexual dysfunction in women with RA. This study suggests that sexual dysfunction among women suffering from rheumatoid arthritis is found when a targeted questionnaire is used to identify it and that the increased disease activity has a negative effect of sexual function.

The aim of this study was to assess the responsiveness to change of the quality of life evaluated by the EuroQol Five Dimensions Questionnaire (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) after biological treatment in a population of rheumatoid arthritis patients. A cohort of patients with RA (n = 29) treated with tocilizumab (TCZ) were analyzed in the study. The inclusion criteria were patients aged between 18 and 65 years, fulfilling American College of Rheumatology 1987 criteria for RA. All patients had inadequate response to methotrexate and with no prior biologic exposure. They were evaluated clinically including Disease Activity Score 28 (DAS28), and the European Quality of Life 5 Dimensions (EQ-5D) to measure the quality of life, and HAD assessed the anxiety and depression status at the initiation of treatment with anti-IL 6 receptor antibody agent and after 6 months. Sensitivity to change was quantified by the effect size (ES) before and after the treatment with TCZ. Among 29 patients with RA included in the study, 25 were females and 4 males. The mean age was 42 years ± 13.4 (SD). Three patients were excluded from the study before 24 weeks because of serious side effects, and five have missing data. The study population exhibited significant decreases in all measures of disease activity at 24 weeks. Physical activity expressed by the Health Assessment Questionnaire (HAQ) score increased through the observation period (for all p

Abnormal puberty is often reported in children suffering from many chronic diseases. Juvenile idiopathic arthritis (JIA) is the most common joint disorder in developing children. The aim of this study was to assess sexual maturation of Moroccan children with JIA and to compare the development of secondary sexual characteristics in children with JIA to children in the general population. Forty children with JIA and 74 healthy controls were included in a cross-sectional study. The diagnosis of JIA was made according to the criteria of the International League of Association of Rheumatology. Every child was examined for the development of genitalia as per criteria given by Tanner. The children with JIA were also divided into 3 groups: pre-puberty (stage 1), puberty (stages 2-3) and post-puberty (stage 4-5), and the association between puberty and cumulative dose of steroids, disease duration, disease activity, height, weight and age was investigated. Forty children with JIA were included (22 male, 18 female); the mean of age of the patients was 11 ± 4.23 years. Puberty in the patients (mean of tanner 2.43 ± 1.36) was lower than controls (2.55 ± 1.36). The prevalence of the children in prepuberty was of 15 (37.5 %) and 8 (20 %) in postpuberty. The prevalence of the children having a delayed puberty was of 6 (15 %) versus 1(1.4 %) in healthy controls (p = 0.005). There was an association between dose of corticosteroids, age at the administration of corticosteroids and the delayed puberty in boys (p = 0.009). In addition, there was no significant association in both sex between this poor puberty and duration of JIA (p = 0.45 in boys and p = 1.99 in girls) and its activity calculated by the DAS28 (p = 0.73 in boys and p = 1). Our study suggests that the puberty is retarded in Moroccan patients with JIA comparing to healthy children and that the dose of corticosteroid and the age at its administration may contribute to delayed puberty in boys.

We aimed to assess the aspects of health-related quality of life (HRQoL) in Moroccan patients with rheumatoid arthritis (RA) and to evaluate the disease-related parameters influencing it. Two hundred fifty-five patients with RA were consecutively included. We assessed sociodemographic characteristics, cigarette smoking status, disease duration, diagnosis delay, joint pain intensity (on a 0-100-mm visual analogue scale), disease activity (by the disease activity score (DAS 28) and biological tests), structural damage (by radiographs scored using the Sharp's method as modified by Van der Heijde), functional disability (by the Health Assessment Questionnaire), extra-articular manifestations, immunological status, and treatments. The Arabic version of the Medical Outcomes Study Short Form 36 Health Survey (SF-36) was applied to assess HRQoL. All domains of SF-36 were deteriorated in a significant way comparing to the general population. The most affected subgroups of SF-36 were role limitation, role emotional, vitality, and social functioning. Women had significantly lower scores of SF-36 compared to men. Patients with decreased levels of education and low socioeconomic status had significantly lower scores of SF-36 (for all p ≤ 0.01). Current and ex-smokers had lower scores in physical domains of quality of life. Patients treated with methotrexate had better scores of mental health. Furthermore, patients receiving biologic agents had better scores of physical and social domains. Decreased scores of SF-36 were significantly correlated with disease duration, joint pain intensity, clinical and biological disease activity, functional disability, and radiographic damage. The level of antibodies against citrullinated peptides had significant correlations with the impairment of physical domains of SF-36. Physical as well as mental aspects of HRQoL in our RA patients were significantly deteriorated. Recognizing complicated relationships between HRQoL and disease-related variables among our RA patients can help to develop further management strategies to improve patients' daily living particularly with the advent of new treatments.

Fatigue is a frequent symptom during ankylosing spondylitis (AS) often under estimated which needs to be measured properly with respect to its intensity by appropriate measures, such as the multidimensional assessment of fatigue (MAF). The aims of this study were to translate into the classic Arabic version of the MAF questionnaire and to validate its use for assessing fatigue in Moroccan patients with AS. The MAF contains 16 items with a global fatigue index (IGF). The MAF was translated and back-translated to arabic, pretested and reviewed by a committee following the Guillemin criteria (J Clin Epidemiol 46:1417–1432, 1993). It was then validate on 110 Moroccan patients with AS. Reliability for the 3-day test–retest was assessed using internal consistency by Cronbach’s alpha coefficient and the intra-class correlation coefficient (ICC). External construct validity was assessed by correlation with pain, activity of disease and other keys variable. The reproducibility of the 15 items was satisfactory with a kappa statistics of agreement superior to 0.6. The ICC for IGF score reproducibility was good and reached 0.98 (IC 95%, 0.96–0.99). The internal consistency was at 0.991 with Cronbach’s alpha coefficient. The construct validity showed a positive correlation between MAF and the axial (r = 0.34) and peripheral (r = 0.32) visual analogical scale, the Bath ankylosing spondylitis disease activity index (BASDAI) (r = 0.77), the first item of BASDAI (r = 0.85), the functional disability by the Bath ankylosing spondylitis functional index (r = 0.64), the erythrocyte sedimentation rate (r = 0.43) and the C reactive protein (r = 0.30) (for all P

The BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is the most widely used instrument for the assessment of disease activity in ankylosing spondylitis (AS). Objective. The aims to investigate whether the alternative BASDAI, here termed as the miniBASDAI [(Question (Q) 1 fatigue + Q2 spinal pain) + mean of (Q5 strength morning stiffness + Q6 duration morning stiffness)] / 3], measures disease activity more accurately in the subgroup of AS patients without peripheral manifestations. One hundred and ten patients were included in this cross-sectional study according to the modified New York criteria for AS. Clinical and biological parameters were evaluated. The disease activity was evaluated by the BASDAI. We calculated the miniBASDAI by omitting both the peripheral joints and the enthesitis questions: questions 3 and 4. Patients were dichotomized into a "P+" group if peripheral manifestations were present (at least arthritis or enthesitis) and a "P-" group, the subgroup without peripheral involvement (with either arthritis or enthesitis). Correlation of the BASDAI and miniBASDAI with other disease parameters were examined with the Spearman's rank correlation analysis. One hundred and ten patients were recruited. The percentage of patients with pure axial disease manifestation without peripheral involvement "P - group" was 42.7%. We found a similarly good correlation of the miniBASDAI with patient global, physician on disease activity, BASFI, ESR and CRP if compared to the correlation of the original BASDAI with these disease parameters, also in the group without peripheral involvement. Our study suggests that the BASDAI remains valid in assessing disease activity in AS patients with and without peripheral manifestations.

We aimed to evaluate the immunological status and its relationships with disease-related parameters of activity, severity and quality of life in Moroccan patients with rheumatoid arthritis (RA). Two hundred forty-five consecutive patients with RA were recruited. The following data were collected: demographic characteristics, disease duration (years), disease activity (evaluated by the disease activity score, DAS28), structural damage (evaluated by Sharp's method as modified by van der Heijde), functional disability (assessed by using the Moroccan version of the Health Assessment Questionnaire, HAQ) and quality of life (by using the Arabic version of the Medical Outcomes Study Short Form 36 Health Survey: the SF-36). Immunological status (rheumatoid factor rate, RF) and antibodies against citrullinated peptides rate (ACPAs) by the Elisa method were examined. ACPAs were detected in 75.1% of patients with a mean rate of 79.2 ± 43.8 UI. RF was detected in 80.8% of patients with a mean rate of 80.1 ± 50.6 UI. Patients with positive RF and ACPAs had higher disease activity, impaired functional ability, severe structural damage, more ocular symptoms and altered aspects of quality of life. In univariate analysis, higher levels of ACPAs were significantly correlated with the age at onset (r = 0.307), disease duration (r = 0.520), disease activity (DAS28) (r = 0.531), Sharp score (r = 0.431), and with the deterioration of all domains of SF-36 (for all p ≤ 0.01). RF levels were correlated with disease duration (r = 0.517), disease activity (r = 0.470), functional disability (r = 0.521), and the alteration of physical domains of SF-36 (for all p ≤ 0.01). In multivariate analysis, the main factors associated to ACPAs and RF levels were functional disability, structural damage and impaired QoL. Furthermore, using the SF-36 scores as dependent variables, the impairment of physical domains and the domain of vitality were significantly associated with ACPA levels while the decrease of the domain of physical function was associated with the level of RF. Our study suggests that the presence and the levels of ACPAs and RF in our RA patients are associated with more active disease, more severe joint damage, worst functional disability and altered aspects of quality of life.

We report a rare case of multifocal septic arthritis associated to spondylodiscitis and endocarditis caused by group A beta-hemolytic streptococcus (GABHS) in an immunocompetent adult, and we discuss diagnosis and therapeutic difficulties, while insisting into the rational use of corticosteroids that seems to be the only risk factor in our patient.

Our aim was to evaluate fatigue and quality of life (QoL) in Moroccan patients with primary Sjögren's syndrome (PSS) and determine their correlates with disease-related parameters. Fifty-seven consecutive patients with PSS according to the American-European Consensus group (AEGG) criteria were included. Demographic, clinical, biological and immunological characteristics for all patients were collected. Xerostomia was demonstrated by histological grading of lower lip glandular biopsy. A Schirmer test was performed to measure lachrymal flow. Oral, ocular, skin, vaginal and tracheal dryness were evaluated by using a visual analogue scale (VAS). Fatigue was assessed by the Multidimensional assessment of fatigue (MAF) and the QoL by using the generic instrument: SF-36. 90% of our patients were women. The mean age of patients was 53.73 ± 7.69 years, and the mean disease duration was 5.38 ± 4.11 years. The mean oral dryness was 68.38 ± 20.29, and the mean ocular dryness was 51.91 ± 14.03. The mean total score of the MAF was 26.73 ± 8.33, and 87.5% of our patients experienced severe fatigue. Also, physical and mental domains of QoL were altered in a significant way, and the severity of fatigue had a negative impact on SF-36 scores. MAF and SF-36 scores were correlated with the delay of diagnosis, the intensity of xerostomia and the activity of joint involvement. A low socioeconomic and educational level had a negative impact on fatigue scores and QoL. Histological grading of lower lip glandular biopsy, immunological status and the severity of systemic involvement had no correlations with fatigue scores or the alteration of QoL. Patients receiving antidepressant have lesser fatigue and those receiving Methotrexate have better SF-36 scores. In our data, there was a high prevalence of fatigue in Moroccan patients with PSS associated with altered QoL. Severe fatigue and reduced QoL seem to be related to the severity of joint involvement, xerostomia and both educational and socioeconomic levels. Also, treatment with methotrexate and antidepressant seems to improve patients' living and QoL. An appropriate therapeutic intervention for depression and articular manifestations in PSS should be applied to improve patients' living.

To determine the prevalence and predictors factors of depression in Moroccan patients with systemic sclerosis (SSc), we conducted a cross-sectional study of 59 Moroccan patients with systemic sclerosis. Patients were assessed by using the Patient Health Questionnaire depression scale "PHQ-9" and through extensive clinical histories and medical examinations. The Arabic version of HAQ and SF-36 was used to assess functional disability and health status, respectively. Forty-six patients (77.4%) presented symptoms of depression. Thirty six (61%) have a major depressive syndrome and 10 (16.4%) have a minor depressive syndrome. The PHQ-9 score was significantly higher in the patient with prolonged disease duration, severe joint pain, higher disease severity, and important acute-phase reactants. Also, depression had a negative impact on physical and mental scores. Systemic scleroderma is associated with a high prevalence of depression. Screening for depression among patients with SSc is recommended and it should be assessed for routinely.

This study aims to evaluate the frequency of fatigue in Moroccan patients with ankylosing spondylitis (AS), and its relationships with disease-specific variables, psychological status, and sleep disturbance. A cross-sectional study included patients fulfilled the modified New York classification criteria for ankylosing spondylitis. To assess fatigue, the first item of Bath ankylosing spondylitis disease activity index (BASDAI) and the multidimensional assessment of fatigue (MAF) was used. The evaluation included the activity of the disease (BASDAI), global well-being (Bath ankylosing spondylitis global index), functional status (Bath ankylosing spondylitis functional index), metrologic measurements (Bath ankylosing spondylitis metrological index), and visual analog scale of axial or joint pain. The erythrocyte sedimentation rate and C-reactive protein were measured. To assess psychological status, the hospital anxiety and depression scale (HADS) was used. Sleep disturbance was assessed by the fourth item of Hamilton anxiety scale. One hundred and ten patients were included, of average age 38.0 years ± 12.6. In our data, 66.4% experienced severe fatigue (BASDAI fatigue ≥ 5). The mean total score of MAF was 26 ± 12.77. The disease-specific variables contributed significantly with both BASDAI fatigue and MAF as dependent variables, accounting for 71.3 and 65.6% of the variance, respectively. The contribution of the depression, anxiety, and sleep disturbance were 24.9, 18.4 and 15.4%, respectively. This study state the importance of fatigue in AS patients. Even though disease activity was the most powerful predictor of fatigue, the effects of psychogenic factors and sleep disturbance, should be taken into consideration in the management of AS.

Vertebral fractures are the hallmark of osteoporosis, responsible for increased back pain, impairment of mobility and functional limitations. These factors have an impact on patients’ health-related quality of life (QOL). The aim of this study was to evaluate the prevalence of vertebral fractures in Moroccan postmenopausal women and to assess their QOL, using an Arabic validated version of QUALEFFO. The study recruited 347 postmenopausal women in obvious good health. We excluded women who had used a drug or who had chronic diseases affecting bone metabolism. All patients had density measurements and spinal radiography. Each vertebral body (T4–L5) was graded using the semiquantitative method of Genant. The mean age was 60 years. Forty-six percent of patients had at least one vertebral fracture. The prevalence ranged from 31% in patients 50–55 years to 69% in patients 65 years and older. Patients with vertebral fractures were older (61.6 ± 8 vs 57 ± 7 years, P < 0.001), had more frequent history of nonvertebral fractures, and had spine and hip BMD values significantly lower (P < 0.001) than patients without vertebral fractures. In multivariate analysis, older age and a history of nonvertebral fractures were the two independent clinical factors of vertebral fractures. The number of fractures was a determinant of a low QOL, as indicated by an increased score in physical function, social function, mental function, and general health [for all (P < 0.05)]. Patients with higher grades of vertebral deformities, i.e., more severe fractures, had low QOL in these four domains. Patient with thoracolumbar fractures had a worse general health than patients with thoracic or lumbar fractures. We found a high prevalence of vertebral fractures probably explained by socioeconomic factors in Morocco. QOL, assessed by an osteoporosis-specific instrument, is decreased in postmenopausal women as a function of both the number and the severity of the vertebral fractures. Treating women with prevalent fractures may avoid a further decrease in their quality of life.

In this study, we evaluated the relationship between enthesitis and clinical, laboratory and quality-of-life parameters in ankylosing spondylitis (AS) in Moroccan patients. Seventy-six patients were included in this cross-sectional study according to the modified New York criteria for AS. All patients had enthesitis involvement. Clinical and biological parameters were evaluated. Enthesitis were assessed by two indices: Mander Enthesis Index (MEI) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Disease activity was evaluated by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Functional impact was assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). The quality of life was measured by the Short form-36 (SF-36). Severity of enthesitis was significantly correlated with disease activity, functional disability and degradation of quality of life. There was no relation between enthesitis indices and disease duration or laboratory parameters. The clinical assessment of enthesitis in AS is an important outcome measure, and enthesitis indices could be used to evaluate disease activity in patients with AS.

We aimed to evaluate diagnosis delay and its impact on disease in terms of activity, functional disability, and radiographic damage in Moroccan patients with ankylosing spondylitis (AS). We recruited 100 Moroccan patients who fulfilled New York Classification criteria for AS. Diagnosis delay was defined as the interval between the first symptom of AS and the moment of a correct diagnosis. Disease activity was evaluated by the bath ankylosing spondylitis disease activity index (BASDAI), functional status by the bath ankylosing spondylitis functional index (BASFI), and radiographic damage by the bath ankylosing spondylitis radiologic index (BASRI). Measurements of spinal mobility were assessed. The average age at disease onset was 28.56 ± 10.9 years. Of the patients, 16% had juvenile-onset AS. Disease duration was 9.5 ± 6.8 years, and the average of diagnosis delay was 4.12 ± 3.99 years. There were no differences in diagnosis delay according to the age at onset, educational level, or the presence of extra-articular involvement. Our patients had altered functional ability. Patients with late diagnosis (>5 years) had statistically significant higher structural damage (BASRI) and severe limited spinal mobility. There was no correlation between diagnosis delay and the activity of disease. Few studies focused on diagnostic delay and its impact in patients with AS. It is necessary in our context to establish an early diagnosis taking into account the high frequency of severe functional disability in Moroccan AS.

The objectives of this study are (1) to evaluate whether the prevalence of osteoporosis and peripheral fractures might be influenced by the educational level and (2) to develop a simple algorithm using a tree-based approach with education level and other easily collected clinical data that allow clinicians to classify women into varying levels of osteoporosis risk. A total number of 356 women with a mean age of 58.9±7.7 years were included in this study. Patients were separated into four groups according to school educational level; group 1, no education (n=98 patients); group 2, elementary level (n=57 patients); group 3, secondary level (n=138 patients) and group 4, university level (n=66 patients). We observed dose-response linear relations between educational level and mean bone mineral density (BMD). The mean BMDs of education group 1 (10.39% (lumbar spine), 10.8% (trochanter), 16.8% (wrist), and 8.8% (femoral neck)) were lower compared with those of group IV (p0.05). Twelve percent of patient had peripheral fractures. The prevalence of peripheral fractures increased with lowered educational levels. Logistic regression analysis revealed a significant independent increase in the risk of peripheral fracture in patients with no formal education (odds ratio, 5.68; 95% , 1.16-27.64) after adjustment for age, BMI and spine BMD. Using the classification tree, four predictors were identified as the most important determinant for osteoporosis risk: the level of education, physical activity, age62 years and BMI30 kg/m2. This algorithm correctly classified 74% of the women with osteoporosis. Based on the area under the receiver-operator characteristic curves, the accuracy of the Classification and Regression Tree (CART) model was 0.79. Our findings suggested that a lower level of education was associated with significantly lower BMDs at the lumbar spine and the hip sites, and with higher prevalence of osteoporosis at these sites in a dose-response manner, even after controlling for the strong confounders. On the other hand, our CART algorithm based on four clinical variables may help to estimate the risk of osteoporosis in a health care system with limited resources.

The objective of this study is to develop and validate a Moroccan version of the childhood health assessment questionnaire (CHAQ), a disability measure for children suffering from juvenile idiopathic arthritis. The CHAQ has been validated in a cross-sectional study in 60 JIA, classified into systemic (33%), polyarticular (38%), extended oligoarticular (6.4%), and persistent oligoarticular (21.6%) subtypes. The CHAQ was tested for reliability and construct validity by correlating the yield of the questionnaire with other disease activity parameters. Disability index was significantly different among the four JIA subtypes. CHAQ proved to be valid in clinically discriminating between healthy subjects and patients with different patterns of JIA. The convergent validity was demonstrated by strong correlations of the disability score with the JIA score set of variables. In conclusion, the Moroccan version of the CHAQ has good psychometric properties. This validated version of the Moroccan CHAQ should help to individual follow-up of children suffering from JIA.

The aim of this study was to evaluate the relationship between historical height loss (HHL) and prevalent vertebral fractures (VF) in postmenopausal Moroccan women and to estimate its accuracy as a clinical test for detecting VF. Two hundred eighty-eight postmenopausal women were studied. All subjects had bone density measurements and spinal radiographs. Vertebral bodies (T4-L4) were graded using the semi-quantitative method of Genant. HHL was calculated as the difference between a patient's tallest recalled height and the current measured height. The mean age was 58.4 +/- 7.8 years. Thirty-one percent of patients were osteoporotic, and 46.5% had VF. Patients with VF had lost more height than those without VF (median, 2.0 cm (0.26-3.3) vs 0.96 cm (0.33-2.4), p0.05). In univariate analysis, HHL was positively correlated to both number and grade of prevalent VF (p0.05). The area under the receiver operating characteristics curve for the ability of HHL to detect VF was 0.60 (95% confidence interval (CI), 0.52, 0.69). Our HHL threshold for detecting VF was1.5 cm, its sensitivity was 58%, and its specificity was 61%. The positive predictive value was 53%, and the negative predictive value was 65%. With HHL1.5 cm, positive likelihood ratio was 1.49 with 95% CI, 1.07, 2.06. Our results demonstrate significant positive associations between HHL, VF, number of VF, and grade of VF. However, this relationship is not clinically pertinent. Consequently, HHL cannot be used as a reliable clinical test for detecting VF in postmenopausal Moroccan women.

We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.

Ankylosing spondylitis (AS) is characterised by a geographic differences in terms of prevalence and clinical expression of the disease. The aim of our study was to describe the actual features of AS in Morocco and we wanted to examine a large population of patients for evidence of phenotypic clustering that could suggest the presence of distinct clinical entities. We investigated 117 patients with a diagnosis of primary AS according to the modified New York criteria. All patients were evaluated according to a standardised data collection form, including demographic variables and disease history with clinical and radiological features. To analyse our data and try to individualise clinical subsets, we applied a two-step cluster analysis using log-likelihood distance measures. Patient's mean age at onset was 25.51 +/- 10.8 year. The mean BASDAI and BASFI score was 33.5 +/- 20.3 and 38.9 +/- 27.5, respectively. Radiographic damage was present in 99.1% of the subjects and radiographic hip involvement in 47.3%. Only 52.6% of patients had been treated with disease modifying antirheumatic drugs. Cluster analysis detected two distinct populations within the data set. Statistically significant differences were found between the two groups particularly concerning activity of the disease, age at onset and the hygienic conditions. Our study revealed that the Moroccan AS was active and severe and suggested that the age at onset and the precarious hygienic level has the greatest capacity to predict activity and severity of the disease.

This study aimed to investigate the proxy-reported Health related quality of life (HRQOL) and its determinants in patients with juvenile idiopathic arthritis (JIA). It was hypothesized that HRQOL would decrease with worsening disease and disability. Data were available in cross-sectional study on children and adolescents with JIA according to the ILAR criteria. Patient demographics, type of JIA, clinical determinants and laboratory parameters relating to JIA were obtained for each patient. Functional disability was assessed using the parent's or children's version of the child health assessment questionnaire (CHAQ). The HRQOL was evaluated using the juvenile arthritis quality of life questionnaire (JAQQ). These questionnaires were previously translated and validated in Moroccan children. A total of 80 participants were enrolled with mean age of 11 [6-17 years], and female predominance (59%). Many patients (42.5%) had oligoarticular subtype; 31.3% polyarticular subtypes and 26.2% systemic form. The mean global score of JAQQ was 2.6 +/- 1.3 (1-6). Patients with persistant oligoarticular had better gross motor function (P < 0.0001), better fine motor function (P < 0.0001), less psychosocial impact (P = 0.001), and less symptoms (P = 0.001) in comparison with polyarticular and systemic subtypes. The HRQOL assessed by the JAQQ was worse in adolescent patients in comparison with children except for symptoms (P = 0.15). The gender (P = 0.95), age at onset of JIA (P = 0.81), and evolution duration (P = 0.34) were not correlated with global score of JAQQ. The diagnosis delay was significantly associated with decrease of HRQOL (P = 0.001). The decrease of HRQOL was correlated with disease activity [pain (VAS), painful and swollen joints, erythrocyte sedimentation rate (for P < 0.0001)], with disability index (CHAQ) (P = 0.001) and presence of hip involvement (P = 0.01). This study suggests that JIA can have a significant adverse effect on the HRQOL of moroccan patients, particularly adolescents with polyarticular and systemic subtypes. Disease duration, disability score (CHAQ) and pain were the strongest determinants of poorer HRQOL.

Idiopathic avascular necrosis (AVN) of the capitate bone is an important, although rare, cause of spontaneous onset of wrist pain. Most cases involve direct or indirect trauma. Only a few reports of idiopathic avascular necrosis have been published. We present a case report of a 32-year-old woman who presented with a chief complaint of a left wrist pain, swelling and loss of all ranges of motions for approximately 1 year. She had no history of prior wrist trauma or steroid use. Laboratory testing for systemic disease or infection were negative. Diagnosis of avascular necrosis of the capitate has been made via plain film radiology, isotope bone scanning, and computed tomography scan. No etiologic factor could be identified. Surgical treatment was recommended, given drilling and autogenous bone grafting. Histological analysis showed necrotic bone. The physical therapy was implemented to restore function. Two months postoperatively, she was almost pain free.

The aim of this study is to assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) in Moroccan patients with knee osteoarthritis. The WOMAC was translated and back translated to and from dialectal Arabic, pre-tested and reviewed by a committee following the Guillemin criteria. The Moroccan version of the WOMAC was administered twice during a 24-48 h interval to 71 Moroccan patients with symptomatic knee osteoarthritis, fulfilling the revised criteria of the American College of Rheumatology. The test-retest reliability was assessed using intra-class correlation coefficient, and the Bland and Altman method. Internal consistency was assessed by Cronbach's alpha coefficient. Construct validity was tested by correlating the WOMAC subscales with visual analogic scale (VAS) of pain, VAS of handicap, maximum distance walked and clinical characteristics. The Moroccan version of the WOMAC showed good reliability, with ICC values of the three dimensions: pain, stiffness and physical function being 0.80, 0.77 and 0.89, respectively. Bland and Altman analysis showed that means of differences did not differ significantly from 0 and that no systematic trend was observed. Internal consistency with Cronbach's alpha for pain was found to be 0.76, and its equivalents for stiffness and physical function subscales were evaluated at 0.76, 0.90, respectively. Construct validity showed statistically significant correlation with all WOMAC subscales and VAS of pain (rho=0.38, 0.42, 0.63 respectively, P

The goal of this study was to determine the impact of ankylosing spondylitis (AS) on the socioeconomic well-being of Moroccan patients. One hundred (100) consecutive AS patients (71 men, 29 women) were included. The socioeconomic consequences were studied by measuring direct costs, indirect costs (consequences on work capacity), and intangible costs (social impact) of AS. The mean age at AS onset was 26.85 years +/- 11.71 (7-64). The mean disease duration of AS was 12.05 years +/- 8.32 (0.5-39). Financial difficulties due to AS were observed in 82% of the patients. In 28% of them, these conditions explained a bad observance to treatments. In 14% of the cases, they led children to leave school to support their handicapped parents. Work disability occurred in 22.9% of initially employed patients. Withdrawal from work was correlated to bad social conditions at work, higher scores of Bath ankylosing spondylitis functional index (BASFI), and absence of adherence to a social security system. Sexual problems were present in 64.2% of the patients and were correlated to higher scores of BASFI. There were also disturbances in housekeeping (65.8%) and in leisure time activities (72.2%). Patients received a financial and a psychological familial support in, respectively, 66 and 87% of the cases. Despite the great familial support, Moroccan AS patients suffer from important socioeconomic consequences because of the illness, the bad socioeconomic conditions, the insufficiency of state help, and the social security problems.

Maffucci's syndrome is a congenital nonhereditary syndrome characterized by a combination of enchondromatosis and hemangiomatosis. It is associated with an increased risk of malignancy. We report a case of a 24-year-old woman who developed severe bone distortion due to generalized enchondromas since the age of 2 years. Physical examination showed a marked shortening of both upper and lower limbs and cutaneous hemangioma in the legs. Radiological study showed symmetric well-circumscribed radiolucent cystic lesions in the hands and severe metaphysical irregularity and a shortening of all long bones. The biopsy of the third right metacarpal showed enchondroma tissue. Histological examination of the skin specimen showed a hemangioendothelioma. The diagnosis of Maffucci's syndrome was established. Abdominal ultrasound, mammography, cerebral computed tomography (CT) scan, and cervical CT were normal.

The study was designed as a case report.The objective of this study was to report an unusual case of bilateral neurogenic heterotopic ossification of the hands in a patient with spinal cord injury.Physical Medicine and Rehabilitation department in Sale, Morocco.A 47-year-old male patient with C5 quadriparesis was admitted in our department for rehabilitation. He had severe spasticity, characterized by extensors predominance in the upper extremities, and an aspect of pudgy fingers at the proximal phalanges in both hands.A plain radiograph of hands demonstrated ossification parallel to the proximal phalanx of the third and fourth digits on the right and of the second and third digits on the left. Serum alkaline phosphatase rate was increased. The diagnosis of heterotopic ossification of hands was retained.Neurogenic heterotopic ossification of hands can occur in quadriplegic patients. Finger extensors spasticity might help toward its development.

Bone infarction refers to aseptic osteonecrosis occurring in the metaphysis and diaphysis of long bones. Hemoglobinopathies, sickle cell disease, and Gaucher’s disease are usually found. Bone infarction is rarely idiopathic. Magnetic resonance imaging has proved to be more specific to identify bone infarction. We report an exceptional case of a unique idiopathic bone infarction of distal tibia, occurring unusually in a patient with juvenile idiopathic arthritis, without major risk factors of osseous infarct, and with atypical clinical and biological abnormalities.

To date, few cases of hemoglobinopathies in patients with rheumatoid arthritis (RA) have been reported (Marino and Mcdonald in J Rheumatol 17:970-972, 1990; Gladman and Bombardier in Arthritis Rheum 30:1065-1068, 1987; Michel et al. in Semin Arthritis Rheum 38:228-240, 2008). These haemoglobin diseases are associated with characteristics abnormalities of the skeleton. Haemoglobin C disease is a benign hemoglobinopathy rarely associated with skeletal disorders [Piéron et al. in la semaine des hôpitaux 57(1-2):22-25, 1981]. We report a case of RA in a 60-year-old woman with homozygous haemoglobin C disease. This coexistence may be a pure coincidence, although we discuss the difficulties with RA treatment in this case due to the unknown effect of anti-rheumatic drugs on the progression of haemoglobin C disease.

Adult-onset Still's disease (AOSD) is an uncommon inflammatory condition of unknown origin and pathogenesis. Pulmonary manifestations are rare and include pleuritis and transient radiological infiltrations. We report a case of a young woman with AOSD who developed unusual respiratory symptoms, with bilateral lower lobar atelectasis and restrictive syndrome and reviewed the literature on it. We illustrate the difficulties in diagnosis of atypical pulmonary defect with unusual radiological aspects and discuss causality relationship between lung abnormalities and Still's disease.

Intra-articular injections of hyaluronan are generally well tolerated; the most common adverse event associated with their use is an inflammatory reaction or a flare at the injection site. Naturally derived sodium hyaluronates have not been associated with pseudosepsis; we describe a case of severe arthritis mimicking acute septic arthritis after naturally hyaluronan. A 70-year-old woman had a medial femorotibial and patellofemoral compartment knee osteoarthritis. Hyaluronic acid injection was indicated because of the persistence of a pain while walking and restricted ability to walk 100 m, as well as the installation of a flessum. She was admitted for an evaluation of a joint effusion occurring within 48 h after the first hyaluronic acid intra-articular injection (first course), with no fever or chills. Joint fluid was found to be cloudy and contained 24,000 cells per mm(3). A knee aspiration was performed to evaluate the possibility of a joint infection. The examination of synovial fluid under phase contrast and polarizing microscopes showed no crystals, and culture on standard media was negative. Acute septic arthritis was considered to be the most likely diagnosis, and probabilistic antibiotic therapy was started. The result of the bacteriological examinations also returned negative. The absence of general signs, particularly fever and chills, with fast effusion regression in less than 4 days did not plead in favor of a septic origin. In front of this beam of arguments, antibiotic therapy was stopped after 4 days. The nonsteroidal anti-inflammatory drug (Nimésulide) was given. The clinical and laboratory test abnormalities were normalized within 2 weeks. Our case has the particularity to occur after using Curavisc, which is known as producing no allergenic reactions. Moreover, the described reaction occurred with the very first infiltration within the very first course.

Background Juvenile idiopathic arthritis (JIA) is the most common arthropathy of childhood. Different diseases affect school attendance to varying degrees. The aim of this study was to assess the impact of juvenile idiopathic arthritis (JIA) on Moroccan children’s schooling. Methods Thirty-three children with JIA were included in this study, having been previously diagnosed according to the classification criteria of the International League of Associations for Rheumatology (ILAR). Seventy-four healthy children were recruited to serve as controls. Data was obtained for all children on their school level, educational performance, and attendance. The rate of absenteeism due to health complications was noted. Results All healthy children were able to attend school (p Conclusions Our study suggested that the schooling of children with JIA was negatively impacted due to the disorder. More studies, with a larger sample of children, are needed to confirm our findings.

Background Several studies have observed an inverse relationship between osteoporosis and spinal osteoarthritis, the latter being considered as possibly delaying the development of osteoporosis. The aim of this study was to determine the association between individual radiographic features of spine degeneration, bone mineral density (BMD) and bone-turn over markers. Methods It was a cross sectional study of 277 post menopausal women. BMD of all patients was assessed at the spine and hip using dual-energy X-ray absorptiometry. Lateral spinal radiographs were evaluated for features of disc degeneration. Each vertebral level from L1/2 to L4/5 was assessed for the presence and severity of osteophytes and disc space narrowing (DSN). For Bone turn-over markers, we assessed serum osteocalcin and C-terminal cross-linking telopeptide of type I collagen (CTX). Linear regressions and partial correlation were used respectively to determine the association between each of disc degeneration features, BMD, and both CTX and osteocalcin. Results Mean age of patients was 58.7 ± 7.7 years. Eighty four patients (31.2%) were osteoporotic and 88.44% had spine osteoarthritis. At all measured sites, there was an increase in BMD with increasing severity of disc narrowing while there was no association between severity of osteophytes and BMD. After adjustment for age and BMI, there was a significant negative correlation between CTX and DSN. However, no significant correlation was found between CTX and osteophytes and between osteocalcin and both osteophytes or DSN. Conclusion In post menopausal women the severity of disc narrowing, but not osteophytes, is associated with a generalized increase in BMD and a decreased rate of bone resorption. These results are consistent with the hypothesis that osteoarthritis, through DSN, has a protective effect against bone loss, mediated by a lower rate of bone resorption. However, spine BMD is not a relevant surrogate marker for the assessment of osteoporosis in the spine in patients with osteoarthritis and debate as to the relationship between OA and OP is still open because of the contradictory data in the literature.

Introduction: Stiff limb syndrome is a clinical feature of the stiff person syndrome, which is a rare and disabling neurologic disorder characterized by muscle rigidity and episodic spasms that involve axial and limb musculature. It is an autoimmune disorder resulting in a malfunction of aminobutyric acid mediated inhibitory networks in the central nervous system. We describe a patient diagnosed by neurological symptoms of stiff limb syndrome with a good outcome after treatment, and a review of the related literature. Case presentation: A 49-year-old male patient presented with a progressive stiffness and painful spasms of his both legs resulting in a difficulty of standing up and walking. The diagnosis of stiff limb syndrome was supported by the dramatically positive response to treatment using diazepam 25 mg/day and baclofen 30 mg/day. Conclusion: This clinical case highlights the importance of a therapeutic test to confirm the diagnosis of stiff limb syndrome especially when there is a high clinical suspicion with unremarkable electromyography

Background The clothing style is an important factor that influences vitamin D production and thus bone mineral density. We performed a case-control study in order to evaluate the effect of veil wearing (concealing clothing) on bone mineral density in Moroccan post menopausal women. Methods The cases were osteoporotic women whose disease was assessed by bone mineral density measurement. Each patient was matched with a non osteoporotic woman for age, and body mass index. All our patients were without secondary causes or medications that might affect bone density. The veil was defined as a concealing clothing which covered most of the body including the arms, the legs and the head. This definition is this of the usual Moroccan traditional clothing style. Results 178 post menopausal osteoporotic patients and 178 controls were studied. The mean age of the cases and the controls was 63.2 years (SD 7) and the mean body mass index was 32.1 (SD 8). The results of crude Odds Ratios analyses indicated that wearing a veil was associated with a high risk of osteoporosis: OR 2.29 (95% CI, 1.38–3.82). Multiparity or a history of familial peripheral osteoporotic fractures had also a significant effect on increasing the osteoporosis risk (ORs: 1.87 (95% CI, 1.05–3.49) and 2.01 (95% CI, 1.20–3.38)). After a multiple regression analysis, wearing the veil and a history of familial osteoporotic fractures remained the both independent factors that increased the osteoporosis risk (ORs: 2.20 (95% CI, 1.22–3.9) and 2.19 (95% CI, 1.12–4.29) respectively). Conclusion our study suggested that in Moroccan post menopausal women, wearing a traditional concealing clothing covering arms, legs and head increased the risk of osteoporosis. Further studies are required to evaluate the clinical impact of the above findings and to clarify the status of vitamin D among veiled women in Morocco.

Patients with rheumatoid arthritis (RA) have been shown to have an increased susceptibility to the development of infections [1, 2]. The exact causes of this increased risk are unknown, but may be related to immunologic disturbances associated with the disease or to the immunosuppressive effects of agents used in its treatment [3, 4]. Recently, the question of whether patients with RA are at increased risk of developing tuberculosis compared with the general population has gained interest in light of reports of serious cases in patients receiving biologic therapies for the disease [5, 6]. Mycobacterium infection is an important cause of morbidity and mortality in patients with RA, especially in prevalent areas [7, 8]. Tuberculosis infection in RA has been reported with an incidence rate of 2.3/1000 patient years, which is higher than in the general population [7]. According to a national study, the prevalence of active tuberculosis in Morocco is estimated to be 160–180/100,000 patients. The aim of this report was to assess the prevalence and the clinical features of tuberculosis infection in RA patients living in Morocco.